Disruptive Innovations by Drs. Tom Pitts and Duncan Brown

Orthodontists will need to set themselves apart as aesthetic experts to thrive in the modern treatment age—here’s how to accomplish that

by Drs. Tom Pitts and Duncan Brown

Thriving in our specialty depends on doing things differently than we’ve done in the past, more efficiently than we ever have, in a manner that engages present and potential patients. Today, that means orthodontists need to master and promote their skills in differentiation, efficiency and experience.

Some challenges orthodontists face today include:

• Fewer patients seeking services from orthodontists.
• More primary care dentists (PCDs) competing to provide orthodontic services to patients.
• The “commoditization” of orthodontics in most patients’ eyes.
• An explosion of corporate practices focusing on high-volume/low-fee models.
• An active strategy by aligner producers to establish themselves as the gatekeepers and advisers for access to orthodontic services.
• Store-purchased aligners.
• Commodity advertising that has led to the growth of direct-to-consumer orthodontic providers.

Identifying a market niche and need

Patients spent just under $17 billion on plastic surgery aesthetic procedures in 2019. (That figure doesn’t include prosthetic aesthetic smile creation with dental veneers and crowns.) Their expectations for superior aesthetics has never been greater, yet the tolerance for prolonged treatment times has never been shorter. Meanwhile, potential patients have no idea of what’s possible for them with progressive aesthetic treatment protocols and hyperefficient mechanics.

Focusing on the variety of diagnostic and treatment processes involved, the aesthetic results attained and the increased efficiency in delivery of services can help orthodontists redefine their role as essential professionals and fulfill the promise of creating aesthetic smiles that can change lives.

Nowadays, patients believe that most any dental practitioner can “straighten teeth,” so competing for patients with other orthodontists and PCDs by cutting costs, using cheaper brackets or other practices that cut overhead without delivering improved results won’t be enough of a differentiator. By focusing on extraordinary aesthetics as the prime differentiator, orthodontists can secure themselves a highly relevant role in the transdisciplinary world of aesthetic providers.

Identifying potential obstacles

Common practice in orthodontics applies hard-tissue-focused diagnostic approaches, outdated clinical treatment protocols and a limited vision of potential aesthetic outcomes. Most conventional orthodontic teaching focuses on occlusal improvements, diagnostic approaches and stability.

The case management strategies that we advocate to optimize aesthetics can be challenging to accept and adopt. It’s been shown that orthodontic treatment is unstable, whether treatment includes extraction or expansion.

The concept of a straight-wire appliance has dominated our profession since Larry Andrews’ breakthrough article led to its development in the 1970s. The straight-wire theory was developed to improve occlusal outcomes and reduce wire bending by designing preadjusted tooth movements relative to the occlusal plane into the appliance. Operator preference such as bracket height, failing to “fill the slot,” manufacturing inconsistency and variation in tooth anatomy negate many potential benefits.

Regardless of ligation method (traditional, active or passive self-ligation), orthodontists continue to be challenged with inconsistent performance of their appliances, especially regarding torsional control and treatment efficiency. Hence, much wire bending is routine.

Research has shown that aesthetic tooth positions have little to do with harming the occlusion. Achieving a great occlusion does not ensure great aesthetics, and the commonly applied strategy to intrude maxillary incisors to reduce overbite can adversely affect aesthetic presentation. Regardless, we strive to obtain great occlusion and function in every case.

Many challenges imposed by rigid adherence to straight-wire theory when using a passive self-ligating mechanism can be overcome with sustaining innovations such as “Active Early” case management protocols. Using progressive, aesthetically motivated case management strategies involving smile-arc protection (SAP), vertical-incisor display (VID) bracket placement, ILSE (immediate, light, short, elastics) and bracket inversion when necessary can improve performance and the quality of the aesthetic result. We use lighter-force square wires for major mechanics and finishing.

We are introducing disruptive innovations into the Pitts 21 appliance that improve performance of the appliance and case management strategies, which can further increase treatment efficiency. We’ve found that patients are eager to accept fixed- appliance therapy that predictably achieves great results in a short treatment time.

Promoting extraordinary aesthetics

Cosmetic dentistry practices spend a lot of time and energy to make sure they differentiate themselves from standard dental practices. Similarly, by establishing an aesthetic “brand,” an orthodontic practice will set itself apart from tooth-based or commodity-based practices.

It must be more than just words. Differentiation in an aesthetic practice begins with an “outside-in” treatment-planning approach that starts with aesthetic potential, continues through treatment processes that address each aesthetic concern and ends with superior aesthetic outcomes, always obtaining great occlusion and function.

Patients don’t know what they want until we show them what they can have, so digital photography and videography are key tools in patient education—before treatment, throughout the process and when celebrating the achieved goals.

For an aesthetic practice, clinical photography alone won’t be sufficient. Artistic photography more effectively communicates the results of treatment and the impact of those results on the patient’s self-assurance. We can’t just show finished beautiful smiles; we must show a dramatic contrast between a patient’s beginning smile and the finished aesthetic smile of other patients.

It’s relatively easy to consistently create high-quality photography or videography in a simple, reproducible and efficient manner. A dedicated DSLR extraoral camera and a small but purposeful photographic studio are not expensive undertakings, and provide the opportunity for consistent and dramatic photography and video.

Clinical auxiliaries often are excited to embrace a role that celebrates the artistic nature of orthodontics, and with practice can deliver excellent-quality photographs and videos in a few minutes. These images and videos are the source of differentiation for an aesthetic practice and provide a wealth of marketing materials for internal and external marketing efforts and branding support.

Extending orthodontics’ Golden Age

Broadening the aesthetic scope of orthodontics requires also considering “white and pink” tissue aesthetics, using positive and negative coronoplasty, soft-tissue refinement and aesthetic recontouring. Refinement of the drape and quality of the soft tissue of the mid- and lower face with fillers and Botox is a very recent entrant into the orthodontic aesthetic arena, and it definitely has a role.

Orthodontics is an aesthetic art, and to be effective, orthodontists must adopt the communication strategies of visual artists. Learn how to present aesthetics! Remember, the patient buys the presentation, not the treatment plan.

In his recent book A History of the Business of Orthodontics, Dr. Norman Wahl considers the time from World War II to 1970 as the Golden Age of orthodontics. Wahl believes that the subsequent oversupply of orthodontists, advent of bonded appliances, explosion of PCD delivery of orthodontic services and downsides of communization are signs that we’ve gone beyond that Golden Age, but we view the future of our specialty in a different manner than he does.

Orthodontists are not compelled to enter an inevitable decline cycle; in fact, the future is bright for aesthetically capable orthodontists. Adopting the proven strategies that have been applied in cosmetic dentistry, embracing the communication approaches of visual artists and improving the ability to effectively present aesthetic case potential to patients and peers can help ensure success.

Implementing time-saving strategies

An important part of differentiation is shortening treatment times while attaining aesthetic goals with fixed treatment.

When necessary, we now can offer treatment strategies that begin with fixed appliances, then transition to clear aligners. We consider this square-wire therapy our breakthrough weapon because we can approach aesthetic smile and width development earlier in treatment—four to eight appointments—before moving into aligners that are made in-house, eliminating any delays related to factory-created models. (We use uLab in-house aligner technology.)

Aesthetic differentiation with high efficiency can be enhanced with this “fixed first” strategy using highly efficient fixed appliances, followed by in-house aligners to further shorten treatment times in fixed appliances.

Using treatment planning software that starts with the patient’s smile and identifies bracket positions to deliver optimal aesthetic smiles will provide further efficiencies. We now offer a “combo” treatment that begins with P21 fixed appliances, then transitions to clear aligners that are made in-house.

We’ve also been working with uLab on a bracket positioning project that will have the software start with the patient’s smile and where to best position brackets for the ultimate aesthetic smile, then provide measurements the orthodontist can use for indirect or direct bonding.

Conclusion

We believe in a future where orthodontists thrive in an aesthetically driven marketplace, working collaboratively with other dental providers to achieve the best aesthetic and occlusal results for our patients. We are excited to be a part of the future!

Case 1

Yadira had been treated by another orthodontist a few years before I met her; she estimated that her previous treatment had taken more than two years. I didn’t have access to her original records, but she appeared to have started out as a Class III patient. Her treatment plan with me revolved around an aesthetic issue, not an occlusal one—I wanted to give her more incisal display and smile arc and proper anterior inclination.

The beginning smiling photo (Fig. 1) reveals she showed only 40% of her upper centrals upon smile, with no smile arc and flared upper incisors. She was the treatment coordinator in my Oregon practice and, after seeing some of my dramatic smile transformations, she couldn’t wait to have me improve upon her smile.

I used SAP++ bracket positioning with Pitts 21 and inverted the upper four anterior brackets (Fig. 2). My first wires were Pitts broad .018-by-.018 supersoft thermal-activated nickel titanium wires (Fig. 3). I placed my disarticulation on the upper first bicuspids at the first appointment and then had her wear immediate light short Class III elastics full time through the bite from lingual of upper second bicuspids and down to the labial of the lower canines. The short elastics were applied to make sure her occlusal plane did not tip in a counterclockwise direction and to widen both arches. She also wore a part-time rainbow elastic from lower canines up over her upper centrals to help widening.

I was able to maintain a beautiful occlusion, upright the inclination of the upper anteriors, extrude upper anteriors slightly and tip the occlusal plane favorably (Fig. 4). She wore very light short Class III elastics (3/16, 2.5-ounce) up until the last month of treatment, which took 14 months total. I think her smile aesthetic improvement was extraordinary.

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Case 2

Hugo, 23, presented with a Class III malocclusion (Figs. 5–7). He had lower anterior crowding and a supernumerary #10 (Figs. 8–10). The palatal #10 was wider and closely resembled the right lateral, so I chose to extract the labial left lateral incisor. The anterior bite was edge to edge.

My plan was to treat Hugo with full fixed passive self-ligating brackets, non-extraction (with the exception of the labial supernumerary lateral) with no miniscrews and nonsurgically.

I placed upper and lower Pitts 21 fixed appliances, including the upper left labial lateral so I could widen the periodontal membrane, so that upon extraction of #10, I could leave the labial plate intact. I inverted the upper and lower anteriors for inclination control, and bracketed for smile-arc protection and VID (Figs. 11 and 12).

I began with widened .014 nickel titanium. I placed bite buttons on the upper first and second molars to disarticulate (Figs. 13 and 14) and began with short Class III light elastics through the bite from the lingual of upper second bicuspids to the labial of lower canines (3/16, 2.5-ounce). The patient also wore an anterior rainbow elastic from lower canines up over upper centrals (5/16, 2.5-ounce) a minimum of 12 hours per day. Of particular note, with full-time Class III elastics, the upper anteriors never flared throughout treatment, showing wonderful 3D control of the square wire in a square slot (Fig. 15).

At seven months (Fig. 15), I had the patient up the force on the light Class III elastics to 3/16, 3.5-ounce full time. I never go above 3.5-ounce elastics for short Class IIIs, and never go above 2.5-ounce elastics for anterior elastics. It took a little extra treatment time, because I waited too long to remove the posterior bite turbos. He faithfully wore his elastics and did a great job with oral hygiene. Having left the posterior turbos on too long, I cut the upper wire behind the second bicuspid in order to sock in the molars quickly.

Not only was his smile transformed, but he had a wonderful aesthetic enhancement to his profile. His occlusal results are also very nice (Figs. 16–20).

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Case 3

Dr. Wassim Bouzid of Constantine, Algeria, used Pitts protocols to accomplish extremely efficient progress on this patient (Figs. 21–25). He began with SAP bracket placement of Pitts 21, inverting the four upper incisor brackets, and placed bite buttons on the upper second bicuspids to disarticulate.

His initial wires were Pitts Broad .014 TA NiTi, and from day one he had the patient wear short, light, through-the-bite Class III elastics (3/16, 2.5-ounce) from the lingual of the upper second bicuspid to the labial of the lower canine.

At four weeks, he moved to .018 wires and kept the Class III elastics full time. After four more weeks, he repositioned brackets; at the fourth appointment, in another four weeks, he moved to .018x.018 Ultra Soft Pitts Broad NiTi.

By the fourth month (Figs. 26–28), he would have been ready for transitioning into in-house aligners if desired, but the patient decided to leave the brackets in place to finish the treatment. You can see that with proper bracket placement, the bite is socked in very well. (Grafting on tooth 25 will be done by a periodontist in the future.)

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